Int J Clin Exp Med 2016;9(11):22590-22594 www.ijcem.com /ISSN:1940-5901/IJCEM0035608 Case Report Why are there so few cases of anterior tibial vein thrombosis? A case report after total joint arthroplasty and literature review Yao Yao1, Xianfeng Yang1,3, Xiaoyu Dai1, Xingquan Xu1,2, Zhen Rong1, Kai Song1,2, Dongquan Shi1,2, Zhihong Xu1,2, Dongyang Chen1, Jin Dai1,2, Qing Jiang1,2 Departments of 1Sports Medicine and Adult Reconstructive Surgery, 3Radiology, Drum Tower Hospital, School of Medicine, Nanjing University, 321 Zhongshan Road, Nanjing 210008, Jiangsu, PR China; 2Joint Research Center for Bone and Joint Disease, Model Animal Research Center (MARC), Nanjing University, Nanjing 210093, Jiangsu, PR China Received July 12, 2016; Accepted September 1, 2016; Epub November 15, 2016; Published November 30, 2016 Abstract: Background: Anterior tibial vein thrombosis is a rare type of thrombosis that occurs in the lower limbs and is not detected by radiography. We present the case of a patient with a hip fracture who developed deep vein thrombosis. Her examination and the presentation of her disease during hospitalization were recorded. Venography was performed and revealed thrombi located in the femoral, popliteal, peroneal, anterior tibial and muscular veins. A better understanding of the mechanism underlying anterior tibial vein thrombosis is needed to decrease the inci- dence of deep vein thrombosis. Keywords: Arthroplasty, anterior tibial vein, thrombosis, calf, phlebogram Introduction the disparity in anatomical distribution has not received much attention. DVT (deep vein thrombosis) is one of the most common complications after major orthopedic The anterior tibial vein originates from the surgery [1]. The clinical symptoms of these dorsal veins and is accompanied by arteries thrombi are often hidden and difficult to detect, with the same names, and then drains into and therefore, standard diagnostic methods the popliteal vein near the tibial-fibular syn- rely mainly on ultrasound and phlebogram [2, desmosis (Figure 2). The main physiological 3]. function of the anterior tibial vein is to collect blood from the muscle in front of the tibia. The distal leg is the most common site of DVTs Anterior tibial thrombosis is an extremely rare [4]. According to previous studies, 20% of these type of lower extremity thrombosis, and iso- untreated calf thrombi have the potential to lated anterior tibial thrombosis is even rarer, progress to the proximal veins or to break off with a reported incidence of only 0-0.3% [10, and cause a pulmonary embolism [5, 6]. Calf 11]. The mechanism responsible for throm- veins consist of three paired veins (the posteri- bosis has not received much attention, and or tibial, anterior tibial and peroneal veins), few objective tests, such as radiography, are each with an identically named arterial com- available. panion, and muscular veins including the sole- us and gastrocnemius veins [7, 8] (Figure 1). The purpose of this case report was to analyze The possible locations of DVTs in the calf are a unique case of anterior tibial vein thrombosis varied, although muscular veins are the most after total joint arthroplasty. The case was diag- common sites, followed by peroneal veins, pos- nosed by a phlebogram. In addition, we review terior tibial veins and finally, the least common the relevant literature on anterior tibial vein sites are the anterior tibial veins [4, 9]. However, thrombosis. A rare case report of anterior tibial thrombosis popliteal and peroneal veins, and the patient had a D-dimer level of 7.64 mg/L. The pati- ent then received thrombolyt- ic therapy with batroxobin for 7 days. After this treatment, we reviewed new images and found that most of the throm- bi had been reduced. As a result, she underwent a hemi- arthroplasty and completed a standard rehabilitation pro- gram after the surgery. She underwent another venogra- phy on the 6th postoperative day to examine the thrombi in the right lower extremity fem- Figure 1. Anatomical scheme (A) and macroscopic photo (B) of crural deep oral, popliteal, anterior tibial vein and popliteal trunk. POP: Popliteal vein, MG: Medialis of the gastrocne- and peroneal veins. Subse- mius vein, LG: Lateralis of the gastrocnemius vein, MPOP: Medialis of the quently, she was discharged popliteal vein, LPOP: Lateralis of the popliteal vein, AT: Anteriortibial vein, and treated with an oral anti- PT: Posterior tibial vein, CS: Centralis of the soleal vein, Pe: Peroneal vein. (Kageyama N, Ro A, Tanifuji T, Fukunaga T. Significance of the soleal vein and coagulant (Figure 3). its drainage veins in cases of massive pulmonary thromboembolism. Annals of vascular diseases. 2008; 1(1): 35-9). Review A PubMed literature search was performed using the search phrases “Anterior tibial vein thrombosis” and “DVT Anterior Tibial Vein”. The sear- ch identified several studies describing anterior tibial vein thrombosis. Only one report contained images of an an- terior tibial vein thrombosis (Table 1). Discussion Previous reports have shown that tibial vein thrombosis may occur in patients during intense physical activity, after surgery and in some other cases [10, 12, 17]. Isolated Figure 2. Transverse view of anterior tibial veins: A: Anterior tibial vein origi- anterior tibial vein thrombosis nates from the dorsal veins and is accompanied by arteries with the same names; B: Compression ultrasound of anterior tibial vein (Arrow). is extremely rare, especially after total joint arthroplasty. The unique mechanism un- Case presentation derlying anterior tibial vein thrombosis requires more detailed investigation. A 78-year-old woman was admitted to the hos- pital 1 month after a right hip fracture. After It remains unknown why there are so few cases admission to our department, venography of anterior tibial vein thrombosis. We speculate revealed thrombi located in her right femoral, that several factors may contribute to the rarity 22591 Int J Clin Exp Med 2016;9(11):22590-22594 A rare case report of anterior tibial thrombosis tibial vein thrombosis, and some articles have indicated that anterior tibial thrombosis is not rare [10]. Although angi- ography is considered to be the gold standard for the assessment for thrombosis, the results obtained through this technique may still be insufficient without a patho- logical diagnosis. We can at- tribute these discrepancies to differences in diagnostic cri- teria. During a phlebogram, a considerable portion of pa- Figure 3. A lateral view of lower deep veins by venography: The femoral vein, tients may receive deficient popliteal vein, anterior tibial vein and peroneal vein showed filling defect. A. assessments due to insuffi- Femoral, B. Knee joint, C. Femoral vein, D. Popliteal vein, E. Lateralis of the cient contrast filling, inade- popliteal vein, F. Anterior tibial vein. quate needle puncture or obscuring metallic materials. of this condition. First, anatomical structures The most common vessels to present inade- and venous hemodynamics may affect the dis- quate filling are the anterior tibial veins. Kaleb tribution and progression of thrombi in the calf. et al. have reported that among 1827 patients Muscle veins in the venous system of the calf who underwent hip surgery, 60 diagnoses of often directly drain into the posterior and pero- anterior tibial vein thrombosis were missed neal veins, and they rarely connect to the ante- [21]. In addition, interrupted imaging or inade- rior tibial vein [8, 19]. Thus, when thrombi origi- quate opacification may cause a false positive nate from muscular veins, they can easily prog- result. Another possible factor contributing to ress into the posterior tibial and peroneal veins, the observed discrepancies is the anatomical but they cannot not progress with the same definition of the anterior tibial vein because ease into the anterior tibial vein [19]. Kageyama venous variation is common in the lower deep N et al [19] has found that the formation of an vessel system. These variable anterior tibial anterior vein thrombosis first requires a by- veins can flow directly into the popliteal veins pass, which indicates that these thrombi are near the joint line. These veins have also some- formed only if the popliteal trunk is extensively times been called the lateral popliteal veins. In occluded. Second, the local venous variation our study, the thrombosis was located in the may also affect the presence of thrombi in the connecting branches. Regarding the use of anterior tibial vein. Normally, blood from the ultrasound for assessment [10], its inferior sen- anterior tibial veins pours into the tibiofibular sitivity and specificity for the diagnosis of distal trunk veins or directly into the popliteal vein. veins, along with its dependence on the skill of The connection between the anterior tibial vein technicians, may decrease the likelihood of and popliteal vein may vary depending on the obtaining reliable results compared with the location of the junction sites, which could be in use of venography. the distal portion, near the joint line, or in the proximal portion [20]. Therefore, patients who Anterior tibial thrombosis is not easy to diag- undergo total joint arthroplasty may exhibit nose and may be hampered by investigators’ variations in vessel structure that aggravate lack of experience or familiarity with the phle- the local hemodynamic disorder, thus poten- bographic technique. We found that it was dif- tially resulting in thrombus formation. In our ficult to distinguish the anterior tibial and pero- study, thrombi occurred at the connection but neal veins in a phlebogram because these also involved the popliteal veins and peroneal veins often overlap, which could lead to a mis- vein. diagnosis. An additional external or internal rotation X-ray may be needed. Another difficulty Previous studies have demonstrated some dis- associated with the diagnosis of anterior tibial crepancies in the number of cases of anterior thrombosis is inadequate visualization of the 22592 Int J Clin Exp Med 2016;9(11):22590-22594 A rare case report of anterior tibial thrombosis Table 1.